Nghiên cứu vai trò chẩn đoán của IMA (ischemia modified albumin) huyết thanh phối hợp với hs troponin t ở bệnh nhân hội chứng vành cấp tt tiếng anh

MINISTRY OF EDUCATION AND TRAINING
HUE UNIVERSITY
UNIVERSITY OF MEDICINE AND PHARMACY

QUANG TUAN PHAM

RESEARCHING THE DIAGNOSTIC ROLE
OF IMA (ISCHEMIA MODIFIED ALBUMIN)
IN COMBINATION WITH HS-TROPONIN T
IN PATIENTS WITH ACUTE CORONARY
SYNDROME

SUMMARY OF DOCTORAL THESIS

HUE – 2019


Research was performed at
UNIVERSITY OF MEDICINE AND PHARMACY, HUE UNIVERSITY

SCIENCE INSTRUCTOR:
1. A.PROF TA DONG NGUYEN
2. PROF VAN MINH HUYNH

Reviewer 1: A.PROF Vinh Nguyen Pham
Reviewer 2: A.PROF Huong Thi Thu Hoang
Reviewer 3: A.PROF Hung Manh Pham

The thesis will be defended at the Hue University thesis dissertation
council at ……

You may know my thesis from:
-

Library of

University of Medicine and Pharmacy, Hue

University
-

National Library

-

Learning Resource Center of Hue city


1
INTRODUCTION
Acute coronary syndrome (ACS) is a dangerous medical emergency
that needs to be diagnosed and treated early. However, early diagnosis of
ACS is still difficult such as: Clinical symptoms and ECG images (ECG) is
not clear, biological markers release blood delays after myocardial
necrosis. Recently many new biological markers have been studied for
diagnostic and prognostic values in patients with ACS.
Recently, IMA (Ischemia Modified Albumin) is an ideal biological
marker in early diagnosis of MI, very early increase in serum (6 to 10
minutes), so it is ideal for early diagnosis of MI. Thanks to the
outstanding advantages of IMA, this biological indicator is valuable in
the future for early detection of ACS. However, there are many

research is needed to assess the role of IMA, especially the coordination
of IMA and hs-TnT. In the world, there are few research has been done
in the combination of IMA and hsTnT in the diagnosis of ACS. To
explore the application of IMA and the combination of IMA and hsTnT in the diagnosis and prognosis of ACS, we have not found any
research in Vietnam. Therefore, we carried out the research:
"Researching the diagnostic role of IMA (Ischemia Modified
Albumin) in combination with hs-Troponin T in patients with acute
coronary syndrome". With 2 goals:
1. Investigate changes in serum IMA, hs-TnT concentrations and
diagnostic values in patients with acute coronary syndrome.
2. Understanding the relationship between serum IMA, serum hsTnT levels and coronary artery lesions and cardiovascular events in
patients with acute coronary syndrome.
2. Scientific and practical significance
Early diagnosis of acute coronary syndrome plays a very important
role because it helps to timely treat and limit its severe complications.
Objective evidence of myocardial ischemia with biological markers is a
“must-have” condition for a definitive diagnosis. Hs-TnT is currently
the only recommended marker in the world, although it can be detected
at very low concentrations but must be detected 3 hours after starting a
heart attack. IMA has shown some advantages: the time has increased
earlier, only 30 minutes after the onset of ACS, high sensitivity and
higher specificity than hs-TnT. Therefore, when combined IMA and hsTnT have the value of elimination or early diagnosis of acute coronary
syndrome compared to a biological marker. Therefore this study has
high scientific significance.
This topic can contribute to practice because IMA and hs-TnT are
biological markers that can be done early, give early results, can be


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tested several times to contribute to diagnostic monitoring with an

association with Clinical events in ACS.
3. Contribution of the thesis
This is the first study in Vietnam on the value of IMA when
combined with hs-TnT in the diagnosis of ACS.
IMA and hs-TnT are all worth diagnosing. IMA and hs-TnT
coordination has better diagnostic value than each individual score.
These are very valuable conclusions in cardiovascular clinical
practice, contributing to help cardiologists have more diagnostic and
predictive tools in clinical practice.
Structure of the thesis
- Structure of the thesis: Including 129 pages: Set of 3 pages,
overview of 27 pages, subjects and research methods of 23 pages,
research results of 34 pages, discussion of 37 pages, 2 pages conclusion,
petition 1 page. The thesis has 59 tables, 29 charts, 5 diagrams, 18
pictures, 153 references: 25 Vietnamese documents, 128 English
documents, 59 documents in the last 5 years.
Chapter 1
OVERVIEW
1.1. DEFINITION OF ACUTE CORONARY SYNDROME
Acute coronary syndrome (ACS) is a term referring to any clinical
manifestations related to acute coronary injury with acute nature, including
unstable angina (UA), Non-ST elevation of myocardial infarction
(NSTEMI) and ST elevation of myocardial infarction (STEMI)
1.2. OVERVIEW OF ISCHEMIA MODIFIED ALBUMIN (IMA)
1.2.1. Structure of IMA
IMA is the human serum albumin, the most abundant protein in the
plasma, produced in the liver, accounting for about half of the serum
protein, synthesized in the liver as preproalbumin, including an Nterminal, early-onset peptide. N-take is removed before new-born
proteins are produced from the granular endoplasmic reticulum. It has a
molecular weight of 67 kDa. These are strong oxidizing compounds that

affect the N-terminal part of albumin. Acetylation is the destruction of
one or more amino acids of the N-terminal fragments resulting in
albumin molecule changes, thus losing the ability to bind to metals.
1.2.2. IMA release in ACS patients
Reduced blood flow is caused by a broken plaque causing oxygen to
tissue deficiency leading to myocardial ischemia. Albumin altered will not
have the ability to attach Cu ++. The attached Cu++ is released from
albumin, where it is absorbed back into the N-terminal end of another


3
albumin molecule in a chain reaction so that the attachment to albumin and
the formation of OH- (hydroxyl) is repeated. IMA concentration increases
very quickly and early in 6-10 minutes when the ischemia happen and
highest increase at 2 - 4 hours and returns to normal after 6-12 hours.
1.2.3. The advantages of IMA
The IMA test showed a positive result when there was a ischemia
heart condition. A negative test indicates that no myocardial ischemia
occurs. IMA detected the majority of patients (82%) with unstable
angina or ACS. Negative values are particularly useful: If there are
negative IMA, negative Troponin and normal ECG, the patient has 99%
of the negative predictive value in the ACS. IMA and ECG is an
optimal combination for non-invasive tests. IMA is a good test because
it occurs early in myocardial ischemia and does not depend on signs of
cardiac muscle necrosis. . IMA negative, negative troponin and no
specific changes in ECG, the diagnostic value is 99% negative in ACS.
1.2.4. Kinetics of IMA
IMA is produced continuously during the time myocardial ischemia
and increased rapidly without interruption. IMA occurs faster than any
other marker. The detection of IMA increased rapidly, present in

peripheral blood within 6-10 minutes from the start of myocardial
ischemia and still increased within a few hours after stopping the
ischemia. This suggests that IMA findings will be clearer and earlier
than other cardiac markers within the first 6 hours after myocardial
ischemia. IMA is used to assess the changing of albumin ratio of
myocardial ischemia, a relatively new sensitive biomarker in
determining myocardial myocardium before or without myocardial
necrosis. IMA can be detected by myocardial ischemia before Troponin
appears and is highly sensitive (82%) compared to traditional diagnostic
tools, which are very valuable for diagnosing myocardial ischemia.
1.3. OVERVIEW HIGH-SENSITIVE CARDIAC TROPONIN T (HS-TNT)
1.3.1 Structure of hs-TnT
The troponin complex consisting of 3 units, troponin C in combination
with Ca2 +, troponin I combined with actin and inhibits the interaction
between actin-myosin, and troponin T in combination with tropomyosin,
thereby binding the troponin complex into fibers fragile. Although most
troponin T is combined into troponin complexes, about 6% troponin T and
2-3% troponin I are dissolved in cytosol. When the heart muscle cells are
damaged, troponin I and T are released immediately from the cytoplasm,
then released from the muscle fiber structure.
1.3.2. Kinetics of hs-TnT
Troponin T is a protein with a molecular weight of 39 kDa. This is a
widely studied biological marker for heart muscle damage. An increase in


4
the concentration of hs-TnT in plasma indicates a clear heart muscle
damage. The secretion of TnT following a cardiomyocyte injury due to
myocardial ischemia can be explained by the following two mechanisms:
During the recovery of myocardial ischemia, there is a loss of cell integrity,

which causes temporary leakage. TnT from cytoplasm. When nonreversible ischemia, intracellular acidosis, activation of proteolytic enzymes
results in the loss of the integrity of the contraction system along with
damage to the membrane structure leading to continuous secretion and
stretching of TnT. Thus, cardiac troponin is an important diagnostic
criterion for detecting, myocardial injury.
1.3.3. Hs-TnT release in patients with acute coronary syndrome
In ACS, TnT is excreted from myocardial cells into the circulatory
system with a 2-phase form. The initial increase in serum TnT levels may
originate from TnT in the cytoplasm of the cell, and the subsequent
increase and prolongation is due to the excretion of TnT attached to the
tropomyosin. For TnT, it usually increases to about 6 hours when there is
cardiac injury but for hs-TnT, it can increase very early, maybe in the first
2-3 hours, it can be detected and reach the maximum in 6-12 hours.
Chapter 2
SUBJECT AND METHODS
2.1. Study subject
The study was investigated at Cardiovascular Center of Hue Central
Hospital from Febuary 2015 to September 2017. Patients who have age
≥ 18, hospitalization and divided into 2 groups: ACS group and healthy
control group.
ACS group: 130 patients was diagnosed with Acute Coronary
Syndrome (ACS) followed by ESC 2015 and VNHA 2016. The criteria
of myocardial infacrtion followed by Fourth Universal Definition of
Myocardial Infarction 2018 ESC/ACC/AHA/ WHF.
Healthy control group: 123 patients meets exclusion criteria of ACS.
2.2. STUDY METHOD
2.2.1. Study design
- A follow-up cross-sectional study.
- We use random selection, convenient sampling method
2.2.2. Steps to conduct clinical research

The studied patients will be given clinical examination, laboratory
testing and full data entry into the survey form on the items available on
the research slip. Monitor patients for 30 days.
2.2.3. Quantification of serum IMA
Quantitative method: Using enzymatic immuno-adsorbing technique
(ELISA = Enzyme Liked Immuno Sorbent Assay) on ELISA Evolis


5
Twin Plus automatic immunoassay, Biorad's chemical supply.
Performed at the Department of Biochemistry, Hue Central Hospital.
This is a homogeneous immunity method, which means that there is
no need to isolate the antigen-antibody complex, which is used to
quantify analytes of low concentration, easily and quickly. The IMA
needs to be quantified as an antigen that lies between two specific
antibodies in the reagent (the Sandwich type usually gives high
sensitivity and specificity).
The marker is HRP (Horseradish Peroxidase), the substrate is TMB
(3.3', 5.5' tetramethyl - benzidine), the sulfuric acid solution will end the
enzyme reaction - the substrate and the color change measured by
spectrometer at 450 nm. The IMA concentration in the analytical sample
will be calculated by comparing O.D (optical density) of the sample with
the standard curve.
Sampling time: Take the test sample at the time of hospital admission.
How to take and store: Take 2 ml of blood for non-freezing test tube, bring
to Department of Biochemistry of Hue Central Hospital. After about 30
minutes, centrifugation 2000 rounds / minute for 15 minutes, then
immediately remove the serum and store the sample at – 20℃. Blood
samples kept for no more than 30 days from the time of collection. After
defrosting, measure IMA concentration.

2.2.4. Quantitative method of serum hs-TnT
Principle: Based on the immune response, the Chemical
Luminesence Immuno Assays (ECLIA) electrochemiluminescence
method. Using two monoclonal antibodies, an antibody is fixed on the
rack (hard phase) and another antibody is marked by a fluorescent
radioactivity: Fluorescence Immuno Assays (FIA), Radio Immuno
Assays technique (RIA ) or a luminescent substance (ECLIA). The
signal emitted by the reaction between the antigen and antibody is
directly proportional to the concentration of TnT in the blood.
Sampling time: Take the test sample at the time of admission and the
second sample is taken after the first sample from 6-12 hours.
Procedure: Take 2 ml of venous blood into a test tube with no
antifreeze, leave for 30 minutes at the laboratory temperature and then
centrifuge 3500 rounds in 10 minutes. Separating the serum that does
not break the red blood cells and quantifying.
Imaging diagnostic tests: electrocardiography, echocardiography,
coronary angiography were conducted and analyzed at a reliable
specialist center for accuracy.
Other biochemical tests and hematology were done at the relevant
department of Hue Central Hospital.


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2.2.5. Data are processed according to medical statistical methods
Using SPSS statistics processing program 20.0 and Medcals and
Exel software to calculate experimental parameters: Experimental
mean, variance, standard deviation.
2.2.6. Ethical research
All patients who meet the criteria for selection and are not included
in the exclusion criteria are invited to participate in the study. Patients

are only included in the study sample when the patient and family agree
to participate in the study. Personal information as well as the patient's
health status is completely confidential.
The tests in the study did not adversely affect the health of patients
participating in the study. During the research process, we absolutely
did not interfere with diagnosis and treatment.
The study was approved and approved by the school's Medical
Ethics Council of Hue Unversity of Medicine and Pharmacy.
CHAPTER 3
RESULTS
3.1. PATIENTS CHARACTERISTICS
3.1.1. Anthropometric feature
The mean age of case group was 65,7 ± 12,3 years, and that of
control group was 65,2 ± 13,5, p > 0,05. In the case group, the
proportion of male patients was 66,4%, which was more than that of
female patients, 36,0% and statistically significant, p < 0,001. The ratio
of male/female = 1,89.
3.1.2. Clinical features of study subjects
Patients admitted to the hospital because of agina pectoris accounted
for 94,6%, higher than that of the control group (48,7%), statistically
significant, p < 0,001. The time from onset until hospital admission in
the case group that is < 6 hours took 44,6% higher than that in the
control group (22,7%), statistically significatn, p < 0,001.
3.1.3. Laboratory features of study subjects:
The percentage of heart failure was 23,1%, death was 11,5%,
cardiogenic shock was 12,3%, arrhythmia was 10,8%. Common
complication was 38,5%.
Group of Killip 1 had the highest proportion of 84,6%, Killip 2 was
8,5%, Killip 3 was the lowest with 1,5% and Killip 4 was 5,4%.
Hematological and biochemical change in patients of case group is

higher than that of control group, statistically significant, p < 0,001. Total
cholesterol, Triglycerid, LDL-C, Urea had no statistically significance.


7
Patients with coronary artery (CA) insufficiency took 91,26%, more than
that with no lesion (8,74%). Patients with 1 branch affected was 35,9% and
that with 2 branches took 34,0%, higher than the proportion of patients having
lesion in 3 branches of CA (21,4%). LAD had the highest rates, 79,6%, with
respectively RCA (58,3%) and LM (1,9%). Coronary ≥ 75% stenosis had the
highest rate 70,59%, coronary with < 50% stenosis had the lowest (10,16%).
Site of injury included LAD with ≥ 75% stenosis with the highest percentage
47,73%. Average Gensini score was 27,80 ± 25,92, median score 21.
3.2. CHANGING IN IMA LEVEL, SERUM hs-TnT AND
DIAGNOSTIC VALUE IN PATIENTS WITH ACUTE
CONRONARY SYNDROME (ACS).
3.2.1. IMA level and hs-Troponin T in patients with ACS
Table 3.8. Level of biomarker in study subjects
Biomarker change
Mean
hs-TnT1 Median
(ng/mL) IQR
Min:Max
hs-TnT2
(ng/mL)

Mean
Median
IQR
Min:Max

IMA
(IU/mL)

Mean
Median
IQR
Min:Max

Total
Control group Case group
p
n = 253
n = 123
n = 130
0,71 ± 1,85 0,010 ± 0,015 1,37 ± 2,40
0,015
0,006
0,23
0,005 - 0,263 0,004 - 0,011 0,037 - 1,540 < 0,001
0,001- 10,0 0,001- 0,111
0,001- 10,0
n = 250
n = 127
1,42 ± 2,66 0,0085 ± 0,0074 2,78 ± 3,19
0,017
0,006
1,26
0,005 - 1,29 0,004 - 0,010 0,167 - 4,470 < 0,001
0,001- 10,0 0,001- 0,045

0,003 - 10,0
n = 253
n = 130
52,51 ± 88,24 24,23 ± 27,14 79,26 ± 114,15
29,94
17,45
46,26
16,48 - 57,32 9,76 - 25,62 32,86 - 80,06 < 0,001
4,02 - 950,51 4,10 - 185,31 4,02 - 950,51

Notes: Level of biomarker in diagnosis of ACS in the case group was
higher than that control group with statistical significance p < 0,001.
Table 3.9. Biomarker change in group of NSTEMI and STEMI
Biomarket change
hs-TnT1
(ng/mL)
hs-TnT2
(ng/mL)
IMA
(IU/ml)

Mean
Median
IQR
Min:Max
Mean
Median
IQR
Min:Max
Mean

Median
IQR
Min:Max

Control (a)
(N = 123)
0,01 ± 0,015
0,006
0,004 - 0,011
0,001 - 0,111
0,0085±0,0074
0,006
0,004 - 0,010
0,001 - 0,045
24,23 ± 27,14
17,45
9,76 - 25,62
4,10 - 185,31

NSTEMI (b)
(N = 46)
0,66 ± 1,42
0,065
0,012 - 0,80
0,001 - 8,053
0,79 ± 1,71
0,16
0,017 - 0,910
0,003 - 10,0
108,02 ± 151,08

63,12
40,78 - 100,26
22,74 - 950,51

STEMI (c)
(N = 84)
1,75 ± 2,73
0,29
0,053 - 2,707
0,003 - 10,0
3,92 ± 3,29
3,60
0,93 - 6,18
0,003 - 10,0
63,52 ± 84,67
40,36
29,85 - 64,55
4,02 - 676,69

p
a&b
<
0,001
b&c
<
0,001
a&c
<
0,001

8
Notes:
- Level of hs-TnT1, hs-TnT2 and IMA in group of STEMI was higher
that that of control group, statistical significance, p < 0,001.
- Level of hs-TnT1, hs-TnT2 and IMA in group of NSTEMI was
higher than that of control group, statistical significance, p < 0,001.
- Level of hs-TnT1, hs-TnT2 in group of STEMI was higher than that
of NSTEMI, statistical significance, p < 0,001.
- Level of IMA in group of NSTEMI was higher than that of
STEMI, statistical significance, p < 0,001.
3.2.2. Level of IMA and hs-Troponin in diagnosis of ACS
Biomarker
Value (IU/mL)
Se (%)
Sp (%)
AUC
p
95% KTC

IMA
28,44
84,6
80,5
0,86
< 0,001
0,81 - 0,91

Figure 3.5. ROC curve of IMA in diagnosis of ACS
Notes:

- Cut point diagnostic ACS of IMA was 28,44 IU/mL with
Se=84,6%, Sp=80,5%, area under the ROC curve was 0,86 with p <
0,001, 95% KTC: 0,81 - 0,91.
- Cut point diagnostic STEMI of IMA was 28,44 IU/mL with
Se=79,8%, Sp=80,5%, area under the ROC curve was 0,82 with p <
0,001, 95% KTC: 0,76 - 0,88.
- Cut point diagnostic NSTEMI of IMA was 29,34 IU/mL with
Se=93,5%, Sp=81,3%, area under the ROC curve was 0,92 with p <
0,001, 95% KTC: 0,88 - 0,96.
- IMA of diagnostic NSTEMI had higher Se, Sp, area under the
ROC curve than that of STEMI.
Biomarker
Value (ng/mL)
Se (%)
Sp (%)
AUC
p
95% KTC

hs-TnT1
0,0165
84,3
87,8
0,90
< 0,001
0,86 - 0,94

* n = 127
Figure 3.8. ROC curve of hs-TnT in diagnosis of ACS

hs-TnT2*
0,0165
89,0
88,6
0,93
< 0,001
0,89 - 0,97


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Notes:
- Cut point diagnostic ACS of hs-TnT1 was 0,0165 ng/mL with
Se=84,3%, Sp=87,8%, area under the ROC curve was 0,90 with p <
0,001, 95% KTC: 0,86 - 0,94.
- Cut point diagnostic ACS of hs-TnT2 was 0,0165 ng/mL with
Se=89%, Sp=88,6%, area under the ROC curve was 0,93 with p <
0,001, 95% KTC: 0,89 - 0,97.
- With cut point of hs-TnT1 > 0,03 ng/mL, hs-TnT1 was statistically
significant in diagnosis of STEMI, Se=86,90%, Sp=96,75%, area under
the ROC curve: 0,947 (95% KTC: 0,908 - 0,974), p < 0,001.
- With cut point hs-TnT2 > 0,026 ng/mL, hs-TnT2 was statistically
significant in diagnosis of STEMI, Se=96,30%, Sp=97,56%, area under
the ROC curve: 0,980 (95% KTC: 0,950 - 0,994), p < 0,001.
- With cut point hs-TnT1 > 0,0185 ng/mL, hs-TnT1 was statistically
significant in diagnosis of NSTEMI, Se=73,91%, Sp=90,24%, area under
the ROC curve: 0,822 (95% KTC: 0,756 - 0,876), p < 0,001.
- With cut point hs-TnT2 > 0,015 ng/mL, hs-TnT2 was statistically
significant in diagnosis of NSTEMI, Se=78,26%, Sp=87,80%, are under
the ROC curve: 0,840 (95% KTC: 0,776 - 0,892), p < 0,001.
Biomarker

Value (ng/mL)
Se (%)
Sp (%)
AUC
p
95% KTC

Delta hs-TnT
0,008
53,08
98,37
0,621
< 0,05
0,56 - 0,68

Figure 3.13. ROC curve of Delta hs-TnT in the diagnosis of ACS
Notes: With cut point, Delta hs-TnT > 0,008 ng/mL was statistically
significant in diagnosis of ACS , Se=53,08%, Sp=98,37%, area under
the ROC curve: 0,621 (95% KTC: ), p < 0,05.
3.2.3. Coordination of IMA and hs-Troponin T in the diagnosis of
ACS
Table 3.18. IMA and hs-Troponin T in the diagnosis of ACS
Biomarker

Sensitivy
(%)

Specificity(%)

IMA and hs-TnT1

IMA and hs-TnT2
IMA_ Delta hs-TnT

70,77
74,02
46,15

98,37
98,37
100,00

Positive
predictive
value (%)
97,87
97,92
100,00

Negative
predictive
value (%)
76,10
78,57
63,73


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Notes:
- When combining IMA with hs-TnT1 in the diagnosis of ACS, Se
increased to 98,37% as positive predictive value increased to 97,87%.

- When combining IMA with hs-TnT2 in the diagnosis of ACS, Sp
and Positive predictive value remain unchanged.
- When combining IMA with Delta hs-TnT, Se and Sp in the
diagnosis of ACS was respectively 46,15% and 100,00%
Table 3.19. IMA and hs-Troponin T with cut point 0,014ng/mL in the
diagnosis of ACS
Biomarker
hs-TnT1
hs-TnT2
IMA _ hs-TnT1
IMA _ hs-TnT2
Delta hs-TnT
IMA
hs-TnT1 (0,0165
ng/mL)
IMA_ Delta hs-TnT

85,37
86,99
98,37
98,37
98,37
80,5

Positive
predictive
value (%)
85,94
87,79
97,87

97,96
97,18
82,09

Negative
predictive
value (%)
84,00
87,7
76,1
78,06
66,48
83,19

84,3

87,8

88,00

84,37

46,15

100,00

100,00

63,73

Sensitivy
(%)
84,62
88,46
70,77
73,85
53,08
84,6

Specificity(%)

Notes:
- With cut point hs-TnT 0,014ng/mL, Se and Sp hs-TnT1 in the
diagnosis of ACS was respectively 84,62% and 85,37% as those of hsTnT2 was respectively 88,46% and 86,99%.
- When combining IMA with hs-TnT at cut point 0,014 ng/mL, Se and
Sp of IMA and hs-TnT1 in the diagnosis of ACS was respectively 70,77%
and 98,37% and those of hs-TnT2 was 73,85% and 98,37% jointly.
- With cut point hs-TnT 0,014ng/mL, Se and Sp in the diagnosis of
clinical types of ACS had the value of hs-TnT respectively: 90,48%,
85,37%; 94,05%, 86,99%; 73,91%, 85,37%; 78,26%, 86,99%.
- When combining IMA with Delta hs-TnT in the diagnosis of
clinical types of ACS, Sp was 100%
3.2.4. Early diagnostic value of IMA and hs-Troponin T in the
diagnosis of ACS
3.2.4.1. Before 6 hours
Bảng 3.21. Comparison of biomarkers in the diagnosis of ACS before 6
hours
Biomarkers
AUC
p

95% KTC
0,867
< 0,001
0,780 - 0,953
IMA ( IU/mL)
0,856
< 0,001
0,777 - 0,935
hs-TnT1 (ng/mL)
Notes: Area under the ROC curve of IMA was higher than that of hsTnT1.


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3.2.4.2 From 6 hours to 12 hours
Bảng 3.22. Comparison of biomarkers in the diagnosis of ACS from 6
hours to 12 hours
Biomarkers
IMA (IU/mL)
Hs-TnT1 (ng/mL)

AUC
0,883
0,897

p
< 0,001
< 0,001

95% KTC
0,794 - 0,973

0,812 - 0,982

Nhận xét: Area under the ROC curve of IMA was lower than that of
hs-TnT1.
3.2.4.3. After 12 hours
Bảng 3.23. Comparison of biomarkers in the diagnosis of ACS after 12
hours
Biomarkers
IMA (IU/mL)
Hs-TnT1 (ng/mL)

AUC
0,804
0,997

p
< 0,001
< 0,001

95% KTC
0,705 - 0,904
0,991 - 1,000

Notes : Area under the ROC curve of IMA was lower than that of hsTnT1.
3.2.4.4. Early diagnostic value of IMA and hs-Troponin T with cut point
0,014ng/mL in the diagnosis of ACS
Table 3.24. Comparison of biomarkers in the diagnosis of ACS
Time
< 6 hours
6 - 12

hours
> 12
hours

Biomarkers
hs-TnT1
IMA
IMA _ hs-TnT1
hs-TnT1
IMA
IMA _ hs-TnT1
hs-TnT1
IMA
IMA _ hs-TnT1

Positive Negative
Sensitivy
Specificity(%) predictive predictive
(%)
value (%) value (%)
74,14
82,14
89,58
60,53
86,21
85,71
92,59
75,00
62,07
96,43

97,30
55,10
87,50
88,89
92,11
82,76
87,50
77,78
85,37
80,77
77,50
100,00
100,00
75,00
100,00
85,07
76,19
100,00
78,13
79,10
64,10
88,33
70,77
98,36
97,87
75,95

Notes:
- Before 6 hours: IMA had higher Se and Sp than those of hs-TnT
- From 6 hours to 12 hours: IMA shared the same Se with hs-TnT

but lower Sp.
- After 12 hours: IMA had lower Sp and Se than those of hs-TnT.
- When combining IMA with hs-TnT, Sp was high before 6 hours as
that of after 6 hours.
3.3. CORRELATION BETWEEN IMA LEVEL, SERUM hs-TnT AND
CORONARY ARTERY LESION AND CARDIOVASCULAR
COMPLICATIONS IN PATIENTS WITH ACUTE CORONARY
SYNDROME


12
3.3.1 Correlation between IMA level and conronary artery lesion
(CA lesion):
- Mean IMA level in group of having CA lesion was respectively 102,67
± 64,40 IU/mL, higher than that of no CA lesion (87,53 ± 130,43 IU/mL) but
there was no statistical significance, p > 0,05. Group of patients having CA
lesion had IMA level with median 68,18 IU/mL, higher than that of group
not having CA lesion 47,5 IU/mL and this difference was statistically
significant, p < 0,05.
- Mean level and median of IMA had no difference between groups
having particular number of branches of CA lesion, p > 0,05.
- There was no correlation between IMA level and number of injured
branches of CA with r = - 0,046 and p > 0,05.
3.3.2. Correlation between IMA level and Gensini score
- There was no differences between mean level and median of IMA
when comparing with median Gensini score, p > 0,05. There was no
correlation between IMA level and Gensini score with r = - 0,064 and p
> 0,05.
3.3.3. Correlation between hs-TnT level and CA lesion
- hs-TnT level in group having CA lesion was significantly higher than that

of group not having CA lesion when comparing mean and median, p < 0,01.
- hs-TnT level in group having ≥ 2 injured branches of CA was higher
than that of group not having CA lesion or 1 branch injured when
comparing median value. This was statistically significant p = 0,001.
Table 3.32. Correlation between serum hs-TnT level and number of injured
branches of CA
Number of injured
branches of CA

hs-TnT1 level (ng/ml)
r1
p1
0,259
0,008

hs-TnT2 level (ng/ml)
r2
p2
0,241
0,014

Notes:
- There was positive insignificant correlation between hs-TnT level
and number of injured branches of CA.
- There was positive insignificant correlation between hs-TnT1 level
and number of injured branches of CA with r = 0,259, p = 0,008.
Correlation formula: y = 0,1755x + 0,9192.
- There was positive insignificant correlation between hs-TnT2 level
and number of injured branches of CA with r = 0,241 and p = 0,014.
Correlation formula: y = 0,545x + 1,9677.

3.3.4. Correlation between hs-TnT level and Gensini score
Table 3.33. Correlation between serum hs-TnT level and Gensini score
hs-TnT1 level (ng/ml)
hs-TnT2 level (ng/ml)
r1
p1
r2
p2
Gensini score
0,284
0,004
0,503
< 0,001


13
Notes:
- There was significant correlation between hs-TnT level and Gensini score.
- There was positive insignificant correlation between hs-TnT1 level
and Gensini score with r = 0,284 and p = 0,004. Correlation formula: y
= 0,0074x + 1,0084.
- There was positive significant correlation between hs-TnT2 level
and Gensini score with r = 0,503 and p = <0,001. Correlation formula: y
= 0,0437x + 1,6678.
- There was positive insignificant correlation between Delta hs-TnT
and Gensini score with r = 0,267, p < 0,01. Correlation formula: y =
1,9636x + 24,519.
3.3.5. Correlation between IMA level and complications of ACS
There was no correlation between IMA level and complications of ACS.
IMA level at cut point 28,44 IU/mL had no statistically significance

in prognosis of time of death complication. IMA level at cut point 28,44
IU/mL had no statistically significance in prognosis of common
complication.
IMA level in group of Killip 1 was 84,52 ± 123,03 IU/mL, higher
than that of group of Killip ≥ 2 (50,34 ± 24,40 IU/mL), there was no
statistically significant difference, p > 0,05.
3.3.6. Correlation between hs-TnT level and complications of ACS
- hs-TnT1 level in group of arrythmia, cardiogenic shock and death
had no statistically significant difference, p > 0,05.
- hs-TnT1 level in group of heart failure and common complications
was higher than that of group with no complication, with statistically
significance, p < 0,001.
hs-TnT1 level at cut point 0,0165 ng/mL had no statistical
significance in prognosis of the time of death complication.
hs-TnT1 level at cut point 0,0165 ng/mL had no statistical
significance in prognosis the time of common complications.
- hs-TnT2 level in group of arrythmia, heart failure and death had no
statistically significant difference, p > 0,05.
- hs-TnT2 in group of cardiogenic shock was 4,20 ± 3,19 ng/mL,
higher than that of groups not having cardiogenic shock (2,61 ± 3,16
ng/mL), statistically significant, p < 0,05 as that in group having
common complications was 3,61 ± 3,24 ng/mL, higher than that of
groups not having common complication 2,30 ± 3,08 ng/mL,
statistically significant, p < 0,01.


14

Figure 3.26. Chance of death in
ACS in terms of hs-TnT2 level

Figure 3.27. Chance of common
complication in ACS in terms of hsTnT2 level
Notes: with hs-TnT2 level> 0,0165 ng/mL, rate of death within 30 days
was higher than that of group with hs-TnT2 ≤ 0,0165 ng/mL.
Table 3.42. Prediction of time of complications in ACS in terms of hsTnT2 level
Hs-TnT1 (ng/mL)
Negative (≤ 0,0165)
Positive (> 0,0165)
p

Time of common complications
Mean (Days)
95% KTC
29,29
27,937 - 30,64
20,04
17,61 - 22,48
0,007

Notes:
- hs-TnT2 level at cut point of 0,0165 ng/mL had the prognostic
value of time of common complications, p = 0,007.
- hs-TnT1 level in groups of patients with Killip ≥ 2 was 1,03 ng/mL,
higher than that of group with Killip 1 (0,16 ng/mL), stastically
significant with p < 0,05.

Figure 3.28. Chance of heart failure
in ACS in terms of Delta hs-TnT level
Notes: With Delta hs-TnT >

0,008ng/mL, chance of heart failure was
higher than that with Delta hs-TnT <
0,008ng/mL, p < 0,05.

Biểu đồ 3.29. Chance of heart
failure in ACS in terms of IMA
level with Delta hs-TnT level.
Notes: With IMA level > 28,44
IU/mL, Delta hs-TnT > 0,008ng/mL,
chance of heart failure was higher
with p < 0,05.


15
Chapter 4
DISCUSSION
4.1. CHARACTERISTICS OF THE PARTICIPANTS
4.1.1. Age and Sex
In our research, the age between the cases and the controls was
similar, the cases had a mean age of 65,7 years (standard deviation:
12,3), with the minimum of 37 years and the maxium of 101 years.
According to sex, our study showed that men took the predominant part,
the ratio of men to women was 1,89. This pattern of ACS patients was
consistent with other researchs in Vietnam and in other countries .
4.1.2. Clinical Characteristics
The main symptom that we found in our resreach was angina (94,6%),
this was much higher than the other (5,4%) and higher than non ACS chest
pain (48,7%), the difference was a statistically significant result. The rate of
patients admission before 6 hours, from 6-12 hours, and later than 12 hours
were 44,6%, 30,8% and 24,6%, respectively. When following-up the ACS

patients in 30 days, we found that early complications were : arrhythmia
(10,8%), heart failure (23,1%), cardiogenic shock (12,3%) and death
(11,5%), these results were similar to other researchs in Vietnam and in other
countries. The Killip class results in our patients were : Killip I (84,6%),
Killip II (8,5%), Killip III (1,5%) and Killip IV (5,4%), these findings were
consistent with other researchs.
4.1.3 Laboratory results characteristics
4.1.3.1. Laboratory Test
Changes in the value of laboratory test between ACS group and nonACS group showed the differences in white blood cell (WBC), serum
creatinine, HDL-C, CK-MB, hs-Troponin T and IMA, these results were
statistically different. The mean value of WBC were 9,95 ± 2,83.
According to serum creatinine concentration, our research showed that
the serum of creatinine in ACS group was statistically higher than the
control group (88,66 ± 22,52 µmol/l and 81,12 ± 18,23 µmol/l,
respectively, p = 0,004). This results was similar to other research.
According to lipid profile, our research showed that there were no
significant difference between the cases and the controls, and the portion
of lipid was similar to other research. The mean value of hs-CRP was
significantly higher in ACS group (9,74 ± 10,96 mg/L) than in non-ACS
group (2,70 ± 4,09 mg/L) with the p value < 0,001, this finding was similar
to other research. CK-MB test results after two time in the ACS group
were both higher than those in the control group (First CK-MB result :
36,34 ± 65,50 ng/mL vs 1,47 ± 0,90 ng/mL, p < 0,001. Second CK-MB
result : 71,73 ± 105,43 ng/mL vs 1,43 ± 0,95 ng/mL, p< 0,001). These


16
findings were similar when comparing to other research in Vietnam and
in other countries.
4.1.3.2 Coronary Injury Characteristics

The results from our research showed the portions of ACS patients
who had one-vessel, two-vessel, three-vessel injuries were 35,9%, 34,0%,
21,4%, respectively. Non-vessel injury was recorded with the percentage
of 8,7%. These findings were similar to other research in Vietnam and in
other countries. The portion of injury in left main coronary artery was
1,6%, left anterior descending (LAD) artery was 79,6%, left circumflex
artery was 41,7% and right coronary artery was 58,3% (Figure 3.4), the
common finding of injury in LAD artery in our research was consistent
with other research. In 187 coronary artery injuries, 75% or greater
stenosis injury was predominant (70,59%). In which, 75% or greater
stenosis of LAD artery was 47,73% (63/132) and this injury in RCA
artery was 33,33% (44/132). As described above, these arteries were the
main blood supplies for the myocardium, therefore, injuries in these
arteries were often found.
4.1.3.3. Gensini Score characteristics
The mean value of Gensini Score was 27,80 ± 25,92 points, the median value
was 21 points. This finding was different in comparison with other research in
Vietnam and in other countries, it could be explained by the differences in
participants and the higher portion of non-ACS group in our reseach.
4.2. LEVELS OF hs-TROPONIN T AND ISCHEMIA-MODIFIED
ALBUMIN (IMA) IN DIAGNOSIS OF ACS
4.2.1. Two-times levels of hs-Troponin T and IMA
The hs-TnT study in case group after two tests with hs-TnT1 result
was 1.37 ± 2.40 ng/mL higher than the control group 0.01 ± 0.02 ng/mL
with p <0.001 and hs-TnT2 result was 2.78 ± 3.19 ng/mL higher than
the controls of 0.01 ± 0.01 ng/mL with p <0.001. This result is similar
to other authors. In our study, the IMA concentration in the ACS group
was 79.27 ± 114.15 IU/mL, which was much higher than the control
group of 24.23 ± 27.14 IU/mL with statistical significance. The results
of our study are different from the other due to the difference in testing

on different machines and measurement units, but all of them give
higher results in the cases than the controls with statistical significance.
4.2.2. Levels of hs-Troponin T and IMA according to clinical
subtypes of ACS
Our study showed that the concentration of hs-TnT at two distinct
times and IMA had the median of the ACS group higher than the
control group with statistically significance in which median of hs-TnT1
concentration was 0.23 ng/mL and of hs-TnT2 was 1.26 ng/mL higher
than the controls at 0.006 ng/mL and 0.006 ng/mL respectively with p


17
<0.001. Similarly, the IMA concentration of the ACS group had the
median of 46.26 IU/mL, higher than the controls of 17.45 IU/mL, which
was statistically significant with p <0.001.
Studying of hs-TnT levels according to the ACS clinical subtypes,
we divided into two clinical subtypes: non ST-segment elevation
myocardial infarction (NSTEMI) and ST-segment elevation myocardial
infarction (STEMI) in which both subtypes have the average level of
hs-TnT higher than the control group with statistical significance. This
is explained by the clinical progress of ACS starting from the episodes
of unstable angina (UA) then to the NSTEMI and then to STEMI, hsTnT is the marker of myocardial necrosis degree, in UA and NSTEMI
the degree of myocardial necrosis is low, so the increase in hs-TnT is
very small, therefore, the concentration of hs-TnT is lower than that in
the STEMI. Similar to other studies of domestic and foreign authors
when comparing hs-TnT levels between the two groups of NSTEMI
and STEMI, the results of hs-TnT were higher than that of the group of
NSTEMI with statistical significance.
Studying IMA concentration in the clinical subtypes of ACS, we
divided into two clinical subtypes, namely, NSTEMI and STEMI in

which both subtypes have higher average levels of IMA than the control
group with statistical significance. This is also explained by the clinical
progression of ACS starting from the episodes of UA and then to the
NSTEMI finally to STEMI, IMA is an early marker in myocardial
ischemia, which increases early and decreases rapidly over time. In UA
and NSTEMI, it appeared earlier, so the increase IMA concentration
was higher than that of STEMI. Other studies of domestic and foreign
authors have shown similar results.
4.2.3. IMA and hs-Troponin T levels in ACS diagnostic
4.2.3.1. IMA levels in ACS diagnostis
Our study of 253 patients in which 130 patients with ACS showed
that the best cut-point of IMA in diagnosis of ACS was > 28.44 IU/ml,
AUC = 0.86, 95% CI = 0.81 - 0.91, sensitivity and specificity was
84,6% and 80,5% respectively with p <0.001. The best cut-point of
IMA in diagnosis of STEMI was > 28.44 IU/ml, AUC = 0.82, 95% CI =
0.76 - 0.88, sensitivity and specificity was 79.8% and 80,5% ,
respectively with p <0.001 (chart 3.2 and table 3.8) and the best cutpoint of IMA in diagnosis of NSTEMI is> 29.34 IU/ml, AUC = 0.92,
95% CI = 0.88 - 0, 96, which had 93.5% sensitivity and specificity of
81.3%, p <0.001. This study shows that the diagnostic value of IMA is
higher in NSTEMI but this difference does not statistically significant.
High sensitivity and specificity of IMA in diagnosis of NSTEMI show
the value of early diagnosis of IMA according to the progresses of


18
clinical subtypes of ACS patients. Our results have a sensitivity and
specificity match with some other studies.
4.2.3.2. hs-Troponin T levels in ACS diagnostic
In our study of ACS diagnosis, the optimal cut-point at hospitalization
was 0.0165 ng/mL with an area under the ROC curve of 0.90 (95% CI: 0.86

- 0.94), with 84.3% sensitive and 87.8% specificity. The second optimal cutpoint for the diagnosis of ACS is 0.0165 ng/mL, but the area under the ROC
curve and the sensitivity, the specificity increased significantly with AUC
0.93 (95% CI: 0.89 - 0.97), sensitivity of 89.0% and specificity of 88.6%.
Our study is similar to a number of other studies on cut-points at admission
as well as high sensitivity and specificity when selecting the optimal cutpoint. Study of the diagnostic cut-points of ACS subtypes showed that the
cut-point hs-TnT1>0.03 ng/mL was significant in diagnosis of STEMI, with
sensitivity of 86.90%, and specificity of 96.75%, area under the ROC curve:
0.947 (95% CI: 0.908 - 0.974), p <0.001 and the cut-point hs-TnT2>0.026
ng/mL has statistical significance in the diagnosis of STEMI, sensitivity of
96.30%, specificity of 97.56%, area under the ROC curve: 0.980 (95% CI:
0.950 - 0.994), p <0.001. In the diagnosis of NSTEMI with hs-TnT1 cutpoints > 0.0185 ng/mL, hs-TnT1 is significant in diagnosing NSTEMI,
73.91%, sensitivity and 90.24% specificity, the area under ROC curve :
0.822 (95% CI: 0.756 - 0.876), p <0.001; With a cut-off point of hsTnT2>0.015 ng/mL, hs-TnT2 was significant in the diagnosis of NSTEMI
with a sensitivity of 78.26%, specificity of 87.80%, area under ROC curve:
0.840 (95% CI : 0.776 - 0.892), p<0.001. This value in our study is also close
to the optimal cut-point of Thygesen K. et. al obtained by the fourth
international consensus on myocardial infarction (MI) in 2018, which is
0.014 ng/mL and is similar to Nguyen Vu Phong, which show an optimal
cut-point to diagnose MI is 0.016 ng/mL with a sensitivity of 93.55% and
specificity of 81.08%.
In this study, we used a cut-point of 0.014ng/mL of hs-TnT in the
diagnosis of ACS in two times of the test, showing the sensitivity and
specificity of 84.62%, 85.37% respectively and 88.46%, 86.99%
respectively. Comparison of the sensitivity and specificity of hs-TnT in
ACS with other authors inside and outside the country has shown
similar results. When using the cut- point of hs-TnT in the diagnosis of
ACS, the sensitivity is similar to the cut point of 0.014ng/mL, but the
higher specificity is insignificant.
In summary, the diagnostic cut point between the two tests is the
same, but in terms of sensitivity and specificity, the second test is

higher than the first, the highly possibility of patients with ACS is
diagnosed. This contributes to the diagnosis or exclusion of ACS.
However, this delay for more intensive treatment. Therefore, the


19
combination of biological markers to increase the ability to early
diagnose ACS is essential.
4.2.3.3. Changing the value of hs-Troponin T in ACS diagnostic
In our study, at Delta cut-point of hs-TnT (hs-TnT1 - hs-TnT2) > 0.008
ng/mL has ACS diagnostic value with area under ROC curve 0.621, p
<0.01, sensitivity of 53.08%, specificity of 98.37%. Our study has higher
Delta hs-TnT than Marco Roff and colleagues is 0.005ng/mL.
4.2.3.4. The combination of IMA and hs-Troponin T in ACS diagnostic
In our study, when combining IMA and hs-TnT1 at the time of
hospitalization in early diagnosis of ACS, the sensitivity was 70.77%,
specificity was 98.37%, positive predictive value was 97.87%. and
negative predictive value was 76.10%. When combining IMA and hsTnT2, the sensitivity increased to 74.02% but specificity was 98.37%,
positive predictive value was 97.92% and negative predictive value was
78.57% unchanged (compared to the former). When combining IMA
and delta hs-TnT showed 46.15% sensitivity, 100% specificity, 100%
positive predictive value, negative predictive value 63.73%. With the
cut- point of hs-TnT of 0.014 ng/mL, the combination of IMA and hsTnT1 showed a sensitivity of 70.77%, a specificity of 98.37%, the
positive predictive value of 97.87% and a value of predictive negative
of 76.1% and when combining IMA and hs-TnT2 also showed similar
results with the sensitivity 73.85%, specificity 98.37% positive
predictive value 97.96% and negative predictive value 78.06%. The
combined results of our cut-point give a similar value to the result of hsTnT at the cut-point of 0.014 ng/mL. This suggests that the combination
of biological markers at the same time when patients are admitted to
hospital will increase the ability to diagnose ACS. Several other studies

also show that the combination of IMA and hs-TnT will increase the
ability to diagnose ACS. In the clinical subtypes of ACS, the results of
our study when using IMA in combination with hs-TnT at the cut-off
point of 0.014 ng/mL in diagnosis of STEMI and NSTEMI has a high
sensitivity and specificity. In combination of IMA and delta hs-TnT in
the diagnosis of STEMI and NSTEMI, the specificity and positive
predictive value of 100% as in diagnosis of ACS.
4.2.4. Early diagnostic values of IMA and hs-Troponin T in the
diagnosis of ACS
In our study, patients since the onset of angina pectoris to admission
before 6 hours had an area under the ROC curve of IMA of 0.867,
higher than hs-TnT1 of 0.856. Patients hospitalized for 6-12 hours
showed an area under the ROC curve of IMA of 0.883 lower than hsTnT1 of 0.897. Patients admitted to hospital after 12 hours have an area
under the ROC curve of IMA of 0.804, lower than hs-TnT1 of 0.997.


20
This suggests that IMA is a very early biological indicator in ACS and
can exist up to 6 hours before the onset of angina pectoris and is a
biomarker with a higher diagnostic value than hs-TnT in the early
hours, however, after 6 hours, the diagnostic value of IMA decreases, at
which time the diagnostic value of hs-TnT is remarkably effective. On
the other hand, the combination of IMA and hs-TnT1 (hs-TnT cut-off
point of 0.014ng/mL) also showed the value of ACS diagnostic before 6
hours and after 6 hours and higher than that of using only one biological
marker. Our research results are similar to other studies.
Thus, in the early stage of ACS, the IMA test has a very high sensitivity,
this marker is very important in early diagnosis and treatment. IMA and hsTnT were evaluated as such an early cardiac marker in the diagnosis of MI.
Therefore, the combination of biological markers early after the onset of
chest pain is essential for a definitive diagnosis of ACS as well as the rule-out

of ACS for an intensive treatment for patients.
4.3. THE RELATION BETWEEN IMA CONCENTRATION,
SERUM hs-TnT AND THE DEGREE OF INJURY OF
CORONARY
ARTERY
AND
THE
ADVERSE
CARDOVASCULAR EVENT IN ACS PATIENTS
4.3.1. The relation between IMA concentration and coronary artery
injury
When comparing the IMA concentration between the coronary artery
injury group and the non coronary artery (CA) injury goup, we found
the mean value of the concentration in the non-CA injury group was
102,67 ± 64,40 IU/mL, this was higher than the CA injury goup (87,53
± 130,43 IU/mL), however, this difference was not stasticically
signigicant (p>0,005). A large number of ACS patients who had
myocardial ischemia without myocardial infraction or myocardial
necrosis had a higher value of IMA concentration than the non
myocardial necrosis group. The degree of myocardial necrosis
depended on the duration of coronary obstruction, therefore, using IMA
for the evaluation of coronary artery injury was not convincing enough,
further research need to be conducted to confirm this issue. Our
research did not find the difference when comparing the IMA
concentration and the number of injured coronary vessels, and there
were no correlation between the number of injured coronary vessels
with IMA concentration ( r= - 0,046, p > 0,05). This result was
consistent with the resreacher Anna Wudkowska.
4.3.2. The relation between IMA concentration and Gensini Score
Our research found that the IMA concentration in the group of the

patients who had Gensini ≤ 21 was higher than in the group of those
who had Gensini >21( 95,35 ± 140,68 IU/mL (median 53,75 IU/mL) vs


21
81,97 ± 109,12 IU/mL (median 41,83 IU/mL), respectively). However,
this result was not statistically significant (p > 0,05). There were no
correlation between IMA concentration and Gensini Score with r = 0,064 and p = 0,520. Our finding was simmilar to the result of Abdullah
Orhan Demirtas, showing no difference between concentration of IMA
and Gensini Score when diving Gensini Score to 3 level : low, medium
and high score (p=0,268), there was a weak correlation between IMA
concentration and Gensini Score (r = 0,25 and p = 0,05).
4.3.3. The relationship between Hs-TnT level and coronary artery
injery
Our research shows hs-TnT1 level in coronary injery group was 1,33 ±
2,37 ng/mL (median: 0,262 ng/mL) higher than group without coronary injery
is 0,04 ± 0,09 ng/mL (median 0,012 ng/mL) which has statistical significance
with p=0,001 and hs-TnT2 in coronary injery group is 3,15 ± 3,39 ng/mL
(median:1,445 ng/mL) higher than group without coronary injery was 0,10 ±
0,20 ng/mL (median: 0,006 ng/mL) which has statistical significance with p
< 0,01 (table 3.30). That was similar to the study of Marcus Hjort and partners
in patients with MI demonstrated hs-TnT level was 0,618 ng/mL in coronary
injery group higher than group without coronary injery was 0,180 ng/mL
which has statistical significance with p < 0,01.
In our study, comparison between the mean level of hs-TnT and the
number of lesion branches found to be insignificant. However when
comparing the median values showed that the more the branch arteries lesion,
the higher hs-TnT level with p = 0.001, significantly. Our study showed that
hs-TnT level and the number of coronary branches lesion have a low level of
positive correlation with r1 = 0.259 and p1 = 0.008, linear regression equation:

y = 0.1755x + 0 , 91912; r2 = 0.241 and p2 = 0.014, linear regression equation:
y = 0.545x + 1,9677. Our research results were similar to other studies.
4.3.4. The relationship between hs-TnT level to Gensini score
In our study, hs-TnT1 level and Gensini score have a low level of
positive correlation, r1 = 0.284 and p = 0.004, linear equation: y =
0.0074x + 1.0084 but hs-TnT2 level and Gensini score have high level
of positive correlation, r2 = 0,503 and p <0.001, linear equation y =
0.0437x + 1.6678. Delta hs-TnT and Gensini score have a low level of
positive correlation, r = 0.267, p <0.01, correlation equation: y =
1,9636x + 24,519. This is perfectly consistent with the pathophysiology
and kinetics of hs-TnT in acute coronary syndrome. Research by both
domestic and foreign authors has shown similar results.
4.3.5. The relationship between IMA level to events in acute
coronary syndrome
In our study, it was found that IMA level in the complication groups
were lower than those without the complication, but this difference was


22
not statistically significant. At the cut-off point of 28.44 IU / mL, IMA
was valuabless in prediction about when death as well as the common
complications in acute coronry syndrome occur, p> 0.05. Our research
is similar to the study of C. Bhakthavatsala Reddy. Hatem Hosam
Mowafy and colleagues’s study also found that IMA was not valuable
in predicting complications after NSTEMI.
Our study also found that IMA level in the Killip 1 group was 84.52
± 123.03 IU / mL higher than the group with Killip ≥ 2 was 50.34 ±
24.40 IU / mL.However this difference was not statistically significant
with p> 0.05. Kiliip classification indicates the severity of acute left
heart failure on acute coronary syndrome. In our research group, there

was no difference in IMA level in heart failure complications, so there
is no difference in the Killip level is appropriate.
4.5.3. Hs-TnT in relation to events of acute coronary syndrome
In our study, hs-TnT1 level in groups with arrhythmic
complications, cardiogenic shock and death was similar to the
uncomplicated group, p> 0.05. However, heart failure group with hsTnT1 level was 3.00 ± 3.33 ng / mL higher than the non-heart failure
group with 0.85 ± 1.77 ng / mL and the general complication with 2.29
± 2, 97 ng / mL was higher than the group without any complication
with 0.81 ± 1.81 ng / mL, which was statistically significant, p <0.001.
At the cut-off point of hs-TnT1 0.0165 ng / mL showed that hs-TnT1
was valualess in the short-term deadth prognosis, p> 0.05 and
predicting general events, p> 0.05. However, hs-TnT2 level in the
cardiogenic shock group was 4.20 ± 3.19 ng / mL higher than the group
without cardiogenic shock was 2.61 ± 3.16 ng / mL which was
significantly, p <0.05 and The general complication was 3.61 ± 3.24 ng
/ mL, which was higher than the group without a general complication
of 2.30 ± 3.08 ng / mL which was significantly with p <0.01. In other
groups, hs-TnT2 level was not different, p> 0.05. At the cut-off point of
hs-TnT2 of 0.0165 ng / mL, there was a predictive value of death or
general complications in the short term with p <0.01. Delta hs-TnT
level> 0.008 ng / mL are more likely to predict heart failure events than
those with delta hs-TnT <0.008 ng / mL. This study showed that the if
hs-TnT level is higher at the next time than the first hospitalization, the
risk of cardiovascular complications or death is higher. Research by
both domestic and foreign authors has shown similar results.
This study also showed that hs-TnT1 level in Killip 1 group was
1.16 ± 2.18 ng / mL (median is 0.16 ng / mL) lower than the group
Killip ≥2 was 2, 49 ± 3.21 ng / mL (median is 1.03 ng / mL), this
difference was statistically significant with p <0.05. In our research
group, there is a difference of hs-TnT1 level in heart failure

23
complications, so there is also a difference in the Killip level is
appropriate.
The group has both IMA> 28.44 IU / mL and Delta hs-TnT> 0.008
ng / mL may appear heart failure complications higher than the other
group. We have not found any document or research regarding this
combination in the prognosis of acute coronary syndrome.
CONCLUSION
From the result of the study on concentration of IMA in combination
with high-sensitivity troponin T carried on 130 patients with ACS and
123 patients without ACS, we conclude that:
1. The value of concentration of IMA and hs-TnT
Concentrations of IMA were significantly higher in patients of ACS
as compared to those in control group.
The cut-off of IMA in diagnosing the ACS was 28.44 IU/mL, the
sensivity was 84.6% and specificity was 80.5%, the area under the ROC
curves was 0.86 with p<0.001, 95% CI: 0,81 - 0,91.
Concontrations of hs-TnT1 và hs-TnT2 were significantly higher in
patients of ACS as compared to those in control group
The cut-off of hs-TnT1 in diagnosing ACS at admission was 0.0165
ng/mL, the sentivity was 84.3%, the specificity was 87.8%, the area
under the ROC curves was 0.90 with p<0.001, 95% CI: 0,86 - 0,94.
The cut-off of hs-TnT2 in diagnosing ACS was 0.0165 ng/mL, the
sentivity was 89%, the specificity was 88.6%, the area under the ROC
curves was 0.93 with p<0.001, 95% CI: 0,89 - 0,97.
The Delta cut-off of hs-TnT in diagnosing ACS was 0.008 ng/mL,
the sensivity was 53.08%, the specificity was 98.37%, the area under
the ROC curves was 0.621, with p < 0.01.

The combination of IMA and hs-TnT in diagnosis of acute coronary
syndrome has a sensitivity of 70.77%, specificity of 98.37%, positive
predictive value of 97.87% and a negative predictive value of 76.10 %
higher than IMA and hs-TnT1 saparated.
Before 6 hours, the value in diagnosing ACS of IMA is higher than
hs-TnT. From 6-12 hours, the value in diagnosing ACS of IMA is lower
than hs-TnT. After 12 hours, the value in diagnosing ACS of IMA is
much lower than hs-TnT.
2. Relationship between concentration of IMA and hs-TnT with the
degree of coronary artery injury and clinical events
IMA concentration was not related to the degree of coronary artery
injury, number of injured coronary arteries and Gensini score, Killip
grade, clinical events in ACS